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(Complete in Duplicate)This form to be used in all applications for special use permits and for rezoning, dividing or consolidating parcels of land, vacating streets, alleys and variances. <br />DateType of Application <br />Owner of Property: Name k'"/) rr( n Phone No. <br />Address <■ / h / _ _ _ _ <br />Applicant (other than owner): Name <br />Address <br />Phone No. <br />Relationship to Owner <br />Engineer: Name_ _ <br />Land Planner: Name <br />Subdivider: Name <br />Phone No. <br />Phone No. <br />Phone No. <br />Location (How do we find it?) <br />Legal Description: /4/ hA^rvI (ic/cK <br />.__. _ , syrrX /Tr_ ^ x / single OwnershipDate '(sq.fV.V- - <br />Date of last division of this property_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br />Do you own any adjoining property <br />Action Requested >/^-1- ' <br />i3 V/~ 'i'rc > -*"> cJe <br />A / <br />O <br />Signature of Applicant <br />RECORD OF ACTION TAKEN <br />Date Action <br />Inspection Deptl: <br />Administrator: <br />Village Council: <br />Village Engineer: <br />Village Attorney: <br />Planning Commission: <br />Village Council: <br />Permit Issued: Date <br />/'I hi <br />^■ /I <br />^ Cl <br />Tc S' A ///J <br />/fh. 7 ..11 <br />f} T)H >>-1 <br />A'/;bh(e7